Multiple Personality: Mental Disorder, Myth, or Metaphor?

Richard Noll's excellent piece on the folly- filled history of Multiple Personality Disorder (aka Dissociative Identity Disorder) turned out to be too hot for the Psychiatric Times to handle.

After having posted the blog, PsychTimes promptly un-posted it. The quick turnaround was apparently occasioned by the fear that those named and blamed by Noll for causing the MPD fad might pursue some form of legal action.

Multiple Personality Disorder has always been controversial and contagious. We are lucky that MPD is now in one of its quiescent phases, but it will almost certainly make a comeback before very long. Recurrent false epidemics have occurred several different times during the last century. The trigger is usually either the widespread copy-catting of a popular movie or book, or the fevered preachings of a charismatic MPD guru, or both.

MPD was an extremely popular diagnosis when hypnosis was in vogue 130 years ago; then emerged again 60 years ago when 'The Three Faces Of Eve' became a best selling book and hit movie; was revived 40 years ago following the vogue of the movie 'Sybil', and its many imitators; and reached a peak 30 years ago when several 'thought leaders' started conducting weekend workshops all over the country minting an army of poorly trained MPD therapists who suddenly diagnosed and treated it in all their patients.

Having seen hundreds of patients who claimed to house multiple personalities, I have concluded that the diagnosis is always (or at least almost always) a fake, even though the patients claiming it are usually (but not always) sincere.

In every single instance, I discovered that the alternate personalities had been born under the tutelage of an enthusiastic and naive therapist, or in imitation of a friend, or after seeing a movie, or upon joining a multiples' chat group- or some combination. It was most commonly a case of a suggestible and gullible therapist and a suggestible and gullible patient influencing each other in the creation of new personalities. None of the purported cases had had a spontaneous onset and none was the least bit convincing.

Why does MPD keep making its periodic comebacks, despite not being a verifiable or clinically useful mental disorder? My best guess is that the labelling of 'alters' offers an appealing and dramatic metaphor, an idiom of distress. Under the influence, pressure, guidance, and modelling of external authority, suggestible individuals find in MPD a convenient way to describe, explain, and express their conflicting feelings and thoughts. But the metaphor often takes on a dangerous and impairing life of its own, feels all too real to the patient, and contributes to regression, invalidism, and a negative treatment response. And many who present with MPD have a real and treatable psychiatric disorder that is masked by it.

At the height of the most recent fad in the 1990's, it seemed that every third or fourth patient was presenting with a long list of newly developed multiple personalities. The modal number of personalities per patient started multiplying exponentially from just 2 to 16. The champion in my experience was a middle aged woman who managed to embody 162 distinct alters- including representatives of both genders, all ages, a wide variety of personality types, and some leftovers from previous lives.

MPD presented an insoluble conundrum for me as Chair of the DSM IV Task Force. I was convinced that it was an iatrogenically inspired diagnosis inappropriately inflicted on vulnerable patients by the poorly trained therapists who came away from their silly weekend workshops armed with an MPD hammer that seemed to fit every patient nail. My own inclination was to wise up dumb therapists and protect vulnerable patients by simply omitting MPD from the DSM.

But my hands were tied. We had layed down strict rules requiring high evidentiary standards before any change could be made in DSM IV. This was intended to prevent arbitrary changes by containing the diagnostic exuberance that typified the experts who were engaged in revising the manual. Any suggestion to expand the system required compelling evidence. But this sword cut both ways. Any change to reduce the system- like eliminating MPD- required equally compelling evidence. I couldn't rid DSM IV of MPD because I had to follow my own rules and there was no compelling proof that MPD didn't exist as a meaningful clinical entity. It was only my personal opinion- however certain I was. The best we could do to reduce the popularity of MPD and inspire caution in its diagnosis was to fill its text description with all the cogent arguments against it.

MPD disappeared in the mid 1990's because of its own failures and dangers, not because of anything we did in DSM IV. It was doomed when insurance companies stopped paying for MPD treatments and patients started suing MPD therapists for malpractice.

I have no doubt that MPD will rise again- it always has. Forgetting the past MPD follies is a proven guarantee we will repeat them. Thanks, Dr Noll, for reminding us.